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rear- r.r r rcpt i eVtiAnrtlA-rtum .................................................... i (Complete lr Triplicate) � Permit No. ..7.7-..� / _ . .... Thio Reen:It ExP Cres I Year From Date Issued Date issued � .....17Z. t. .... ...... .............. .... ............... Application Is hereby evade to the San Joaquin Local Health District for a permit to construdd and Install the work herein described. This application is made In compliance with County Ordinance No. 549 and existing Rules and Regulationst JOB ADDRESS/LOCATIONN.. .. .. ............................. ...CENSUS TRACT ............. Owner's Name ....AL1 'I�c Jam.... ...._ .......... .................. .. ... ...................................Phone .. . 1�-��. ....... Addressice . ., . . ...............................City ..... .. ...... ... ._....,....,.... ... . .._. Contractor's Name ..._ _ ......................................License # _... Phone _ Installation will serve: a danceartment House❑ Commercial❑Trailer Court D Motel O.Other............................................ i J plumber of 1iving units:-_-- _.--- Number of bedroomsg .._.._Garbo a Grinder ............ lot Size ............................................ Water Supply: Public Systerh an4.nam_ e . ........ ....................._-.-----..-..._ --..---.......--------.--.----.-------------------------Private Character of soil to'a depth of 3 feet.. Sand❑ Silt❑ Clay ] Peat 0 Sandy Loam ❑ day loam ❑ Hardpan❑ Adobe❑ Fill Material ............If yes,type .. ... .... .... ... 7 Mot plan; showing size k lot,��location of system In relation to wells, buildings, etc. must be placed an reverse side.) R NEW INSTALLATION: (No septk tank or seepagepit permitted If public sewer is available within 200 feet,) �+ PACKAGE TREATMENT [ ] SEPTIC TANK( Size....................... ... liquid Depth si Capacity/,ZQD�Ype • jj .... ?Materia(...................... No. Compartments ....... . .. .. F: Distance to nearest: Well' .1�1 ,_ ...Foundation ..�d p. as .... ---•----•----._... ! -----••............. Pro line ....:..----------•---� t LEACHING LINE [ ] No. of Lines .6------------_--- length of- each line-_yQ......... .......... Total Length ��............... so 'D' Box .l........ Type Filter Material _.._.._Depth Filter Material ....._...... {......................I........ Distance to nearest.• Well .................. Foundation .......... Property line .......................6 F SEEPAGE PIT ) ] Depth . Diameter . Number . Rock Filled Yes ❑. No Water Table Depth ..Rock Size .NA ` Distance to nearest, Well ....Foundation . Prep. Line.................... of REPAIR/ADDITION(Prey. Sanitation Permit --. Date ` D11 p ......................................... ._._.......__..... ....._..... ..) Septic Tank (Specify Requirements) ....................................... - -' Disposal .Field (Specify Requirements) ................................ :..........-........................................................ ....�................................ -� .............................................. ................................................................... ............• --.....---•-•--,...........•---....... ... -----• ...._•---I......-----:..... ......-_:................_.._._..-----........._..... . (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hants owner or Ilcon- sed agents signature certifies the following: "I certify that in the performance of the work,for-whlc hthis permit 6 Issued, I shall not employ any person In such manner as to become subject to Workman's Compensation.laws of California," T Signed ... ' . ....... Owner By ........................................................... --- ..--•---•...............--•---•---------••-••--- - title ......_.__..._..---.._...............:... .. ..................... i# other than owner. r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .__ _.. ---... -•--- ....,---••..................... DATE :..... ...... :.:�� "- BUILDING PERMIT ISSUED ==--------------•-....._..----._...._........._... _DATE ..................................... ADDITIONALCOMMENTS .•----- --•--------------------------------------- ---------------__.......------•-•-.......----.._......_......._....---..._. ._.:_.....•---..._............ ................................--------------------------------------------------------- - . ---- ------ . - .............................................. .................. ...... ....-- ----... G Final Inspection by: ................. �,,................... ...........Date .. cT� . C. 13 2h1-68 itt3v. '1 SAN JOAQUIN LOCAL HEALTH DISTRICT 6/7h 3M FIR t . cco11NTINo �7,,. .E CODE++ )TEE INFO AMOUNT REMIT 6 f ED As FIECOwn 6Y ! TE -I SR 1 i@AaT NIMBER INVOICE F 67•